Table 1 Summary of main recently completed and ongoing clinical trials employing ctDNA and NGS

GOZILA (UMIN000016343)

Screening study for companion trials

Metastatic and/or unresectable GI and breast cancers; other solid tumors with specific gene alterations

1,687

Guardant360™

To evaluate the utility of circulating tumor DNA (ctDNA) genotyping. Compared trial enrollment using ctDNA vs. tumor tissue sequencing in the same centers and network

ctDNA-based screening significantly shortened the screening turnaround time and improved the trial enrollment rate without compromising treatment efficacy compared with tissue-based screening [97]

COLOMATE (NCT03765736)

Phase 2 umbrella screening trial

Metastatic colorectal cancer (mCRC) patients with progressive disease

500

Guardant360™

To perform ctDNA-based genomic profiling to enable matching to molecularly targeted therapies

Study ongoing

SLLIP (NCT03248089)

Observational

Treatment naïve, metastatic non-squamous NSCLC

182

Guardant360™

To demonstrate the non-inferiority of cfDNA-based versus tumor tissue-based genotyping

The primary objective was met with cfDNA identifying actionable mutations in 46 patients vs. 48 by tissue. ORR and PFS in patients receiving targeted therapy based on tissue or cfDNA were similar to those previously reported. Confirms that cfDNA-based first-line therapy produced outcomes similar to tissue-based testing [98].

TARGET

Feasibility and screening trial

Solid tumors

100

641 cancer-associated-gene panel in a single ctDNA assay

Two-part study divided into Part A, feasibility of the workflow, ctDNA and tumor sequencing validation, formal reporting and setting up the MTB; and Part B, expansion to match patients to clinical trials and therapies in real time

Four patients experienced an objective response, which represents 36% of the treated patients and 4% of the whole included cohort. Overall, TARGET shows the feasibility of using ctDNA to successfully guide a subset of patients to specific treatment regimens in early-phase clinical trials [19].

plasma-MATCH (NCT03182634; EudraCT2015-003735-36; ISRCTN16945804)

Multicenter, multicohort, phase IIA platform

Advanced breast cancer

1034

Digital droplet PCR for PIK3CA, ESR1, HER2, and AKT1 and Guardant360™

To assess the accuracy of ctDNA testing in advanced breast cancer and the ability of ctDNA testing to select patients for mutation-directed therapy

ctDNA testing offered accurate, rapid genotyping and enabled the selection of mutation-directed therapies, with sufficient clinical validity for adoption into routine clinical practice. Demonstrated clinically relevant activity of targeted therapies against rare HER2 and AKT1 mutations. [99]

NILE (NCT03615443)

Prospective, observational

Advanced nonsquamous non–small cell lung cancer

282

Guardant360™

To demonstrate noninferiority of cell-free circulating tumor DNA (cfDNA)-based tumor genotyping compared to tissue-based genotyping to find targetable genomic alterations

cfDNA detected guideline-recommended biomarkers at a rate similar to tissue testing and outcomes based on ctDNA profiling were comparable to previously published targeted therapy outcomes with tissue profiling, even in community-based centers [100].

IMAGE (NCT01939847)

Non-randomized feasibility study

Progressive, metastatic, triple-negative breast cancer

26

FoundationOne® panel on tumor tissue and blood

To evaluate the feasibility of obtaining a new metastatic tissue biopsy by performing tissue NGS and providing molecular tumor board recommendations within 28 days. In addition, ctDNA from plasma ctDNA was evaluated via NGS, although results were not used to match treatments.

The study highlighted the benefits of parallel ctDNA analysis, as challenges were encountered when trying to obtain NGS results from tumor tissue in the desired timeframe and also due to insufficient sampling. Analysis of ctDNA yielded informative results in 92% of the patients [101].

ICT (EudraCT2014-005341-44

Prospective, two-stage phase II

Advanced and refractory carcinoma

24

50-gene hotspot panel (not cfDNA-specific) and shallow whole-genome sequencing

To evaluate the success of a targeted therapy selected by profiling of ctDNA and tissue in patients with advanced and refractory carcinoma

Informative ctDNA results were obtained in 20/24 patients. A potential tumor-specific drug could be matched in 11 patients and 7 patients received a matched treatment based on ctDNA results. No patient reached the primary endpoint of a PFS ratio > 1.2, indicating that more innovative approaches to study design and matching algorithms are necessary to achieve improved patient outcomes [102]

InVisionFirst-Lung

Multicenter prospective clinical validation study

Untreated advanced NSCLC

264

InVisionFirst®-Lung Circulating Tumor DNA Assay

To prospectively examine the application of plasma-based comprehensive genomic profiling (CGP) in untreated, newly diagnosed, advanced-stage non–small-cell lung cancer (NSCLC) compared with CGP using biopsy tissue

Assay demonstrated high concordance with tissue profiling with suitable sensitivity and specificity for single-gene ctDNA assays. ctDNA-based molecular profiling enabled detection of 26% more actionable alterations compared with standard-of-care tissue testing [103]

SOUND

Open, prospective, interventional, non-randomized IVD study

Patients with locally advanced and/or metastasized carcinoma for whom no further evidence-based treatment is established or who have no satisfactory alternative treatments

200

FoundationOne®CDx for tissue analysis,

FoundationOne®Liquid CDx for ctDNA analysis, AVENIO ctDNA Surveillance panel for biomarker monitoring

One of the largest prospective studies in Austria exploring treatment rates and outcomes of CGP-driven targeted treatment in patients with advanced or metastasized cancer. Additionally, the treatment decision process will be supported and documented by the NAVIFY Tumor Board software

Study ongoing

Circulating Tumor DNA (ctDNA) for Early Treatment Response Assessment of Solid Tumors (NCT04354064)

Observational cohort study

Diverse solid tumors

3362

Not given

To enable earlier detection of disease recurrence through analysis of ctDNA from plasma and urine

Study ongoing

COBRA (NCT04068103)

Interventional, randomized phase II/III study

Stage IIA colon cancer

1408

GuardantHealth LUNAR panel

To compare the rate of ctDNA clearance in “ctDNA detected” patients treated with or without adjuvant chemotherapy following resection of stage IIA colon cancer. (Phase II). To compare recurrence-free survival (RFS) in “ctDNA detected” patients treated with or without adjuvant chemotherapy following resection of stage IIA colon cancer. (Phase III)

Study ongoing

Studies with associated ctDNA analyses although ctDNA not trial focus

Trial/study (Identifier)

Trial type

Tumor type(s)

No. of patient used for ctDNA analysis

NGS methods for ctDNA analysis

Brief description of ctDNA use

Summary of main findings with implications for ctDNA use

I-PREDICT (NCT02534675)

Cross-institutional, prospective, observational, navigation

Patients with incurable malignancies with aggressive biology

12

FoundationACT® (62-gene panel)

NGS was also performed on ctDNA to extend the possibilities identifying actionable targets and personalizing treatment with combination therapies

Achieved a treatment matching rate of 49% (73 of 149 patients), higher than in other precision medicine trials. This was likely the result of several key factors: Using a large panel of cancer-related genes, including MSI status, PD-L1 IHC and ctDNA results [33]

PALOMA-3 (NCT01942135)

Randomized, double blind, placebo controlled, Phase 3

Hormone receptor + HER2-negative metastatic breast cancer after endocrine failure

459 patients with a baseline plasma sample available, 287 of these having a matched EOT

Whole-exome sequencing and targeted sequencing with a custom 14-gene panel

Plasma ctDNA exome sequencing of paired baseline and EOT samples from 195 patients enrolled on the PALOMA-3 trial was performed to investigate the mechanisms of resistance to the CDK4/CDK6 inhibitor palbociclib plus fulvestrant versus fulvestrant alone

ctDNA results showed that acquired resistance to fulvestrant and palbociclib is associated with clonal evolution and acquired mutations in RB1, PIK3CA, and ESR1. These results highlight the potential of ctDNA to guide the next line of treatment [104]

HERACLES (NTC03225937)

Proof-of-concept, multicenter, open-label, phase II trial

Patients with KRAS exon 2 (codons 12 and 13) wild-type and HER2-positive metastatic colorectal cancer refractory to standard of care

30

Guardant360™ assay

Plasma from patients treated with trastuzumab and lapatinib in the HERACLES study was collected before treatments very 15 days during therapy, and at the time of radiographic progression

Mutations in RAS and BRAF were detected in pretreatment plasma samples and were associated with primary resistance to HER2 treatment. Patients enrolled had received anti-EGFR therapy prior to enrollment, which led to the emergence of RAS-mutant clones. This study suggests that ctDNA may be used to determine patient eligibility for HER2-targeted therapy to spare patients unnecessary treatment [105]

IMvigor010 (NCT02450331)

Phase III, open-label, randomized, multicenter

Patients with high-risk muscle-invasive urothelial carcinoma

581

Whole exome sequencing of tumor tissue followed by personalized Signatera™ ctDNA assay

Evaluated outcomes in patients who had undergone surgery and were evaluable for ctDNA from a randomized phase III trial of adjuvant atezolizumab versus observation in operable urothelial cancer

ctDNA testing at the start of therapy (cycle 1 day 1) identified 214 (37%) patients who were positive for ctDNA and who had poor prognosis. ctDNA-positive patients had improved DFS and OS in the atezolizumab arm versus the observation arm. Data suggest that adjuvant atezolizumab may be associated with improved outcomes compared with observation in patients who are ctDNA-positive and at a high risk of relapse, which could shift approaches to postoperative care [106]